[Computerized tomography of intracranial tuberculous lesions. 2 case reports]

In contrast to the numerous publications on supratentorially located tuberculomas, reports on infratentorial tuberculomas, demonstrated by computed tomography, are relatively few in number. Although nowadays precise localization has become possible via computed tomography, a tuberculoma cannot be identified unequivocally by computed tomography. The appearance of tuberculous lesions in CT depends on the extent the lesion has advanced at the time of the investigation and whether or not tuberculostatics have already been administered. In the posterior cranial fossa, brain stem tuberculomas must additionally be distinguished from cerebellar tuberculomas and tuberculous brain abscess from solid tuberculomas. The problem of tuberculous lesions in computed tomography is discussed with reference to a left frontotemporal tuberculoma and a vermis tuberculoma demonstrated by computed tomography and removed surgically.

Intracranial tuberculoma and the CT scan

Computerized tomography (CT) has greatly influenced the diagnosis and management of intracranial tuberculomas and has helped us to formulate guidelines for the management of these lesions. Solid and ring-enhancing lesions seen on CT scans are diagnostic of tuberculoma if supported by other clinical and ancillary criteria. Conservative management of intracranial tuberculoma is usually indicated because serial CT scans have shown complete disappearance of these lesions with antituberculous therapy. Only lesions associated with raised intracranial pressure and CT evidence of a mass effect should be considered for surgery. Nonresponse to antituberculous therapy, as judged by serial CT scanning, should raise doubts regarding the diagnosis of a tuberculomatous lesion, and therefore such lesions should be subjected to surgery and histopathological confirmation. Representative clinical cases illustrating the principles of diagnosis and management of intracranial tuberculoma with the help of CT scanning are briefly described and discussed.

[Cystic cerebral tuberculoma--a case report]

A case of cystic cerebral tuberculoma is presented. A 63-year-old man was admitted initially to a sanatorium in May, 1983, for the treatment of pulmonary tuberculosis. He developed headache and vomiting, and suddenly had a right hemiconvulsion on September 27, 1983. Gradually he developed right hemiparesis and motor aphasia. CT scan revealed a well defined, ring-like enhanced mass with multiloculated cysts in the left fronto-parietal lobe. So, he was transferred to our hospital on February 3, 1984. Neurological examination revealed that he had motor aphasia and right hemiparesis. Left carotid angiogram showed light tumor stain in the left fronto-parietal lobe, and 99mTc brain scan detected increased uptake in this area. A left fronto-parieto-temporal craniotomy was performed and a subcortical mass was excised en bloc. The mass had multiloculated cysts containing xanthochromic fluid. Histologically, the mass was cystic cerebral tuberculoma. Cystic cerebral tuberculomas have rarely been reported even before the introduction of antituberculous chemotherapy. The pathogenesis of the cysts in this particular case was considered that the caseous material would have undergone liquefaction by enzymes liberated from degenerated and fragmented inflammatory cells.

[Cerebellar tuberculoma. Clinical and radiological course]

A six-year-old child with intracranial hypertension is described. Cranial computed tomography showed an expansive mass surrounded by a contrast enhancement ring in the right cerebellar hemisphere. Chest roentgenograms showed signs of pulmonary tuberculosis. Intracranial lesion was diagnosed as a tuberculoma and treated with tuberculostatic agents. Serial computed tomography scans showed a reduction of size of tuberculoma and appearance of a residual calcified image.

Management of intracranial tuberculoma in children

Thirty-one patients were studied during a period of 3 years in order to identify features helpful for the diagnosis of tuberculoma. Sixteen had a history of pyrexia, 4 had had contact with cases of tuberculosis, the tuberculin test was positive in 15, the erythrocyte sedimentation rate (ESR) was elevated in 23, and 5 had concomitant tuberculous infections. Three had multiple lesions and 10 showed CT scan features suggestive of tuberculoma. Nineteen patients were successfully treated with drugs alone; seven needed surgery because they failed to respond to drugs clinically or because CT indicated no improvement. One patient proved to have a tumor, having shown an absence of response to drugs; four were operated on without drug trial because they were thought to have a tumor, and 1 needed surgery because of the mass effect of a very large tuberculoma. Infratentorial lesions associated with hydrocephalus were treated with ventriculoperitoneal shunts.

Computed tomography in CNS tuberculosis

Computed tomography (CT) was performed in 14 cases of tuberculous meningitis (TBM), 12 of which were examined during the acute phase of the disease. CT findings in these cases included internal hydrocephalus (6/12), internal combined with external hydrocephalus (2/12), focal lesions consistent with localized encephalitis (3/12), diffuse brain edema (1/12), and middle cerebral artery infarction (1/12). In comparison to 32 cases of nonspecific bacterial meningitis, internal hydrocephalus was found significantly more often in TBM than in nonspecific meningitis (p less than 0.01) making CT an additional tool for the differentiation of these conditions in doubtful cases. In addition, CT features of 2 cases of cerebral tuberculoma are presented.

Changing concepts in the treatment of tuberculomas of the brain

Tuberculomas of the brain in children constitute 5% to 8% of intracranial space-occupying lesions in developing countries. These have in the past been treated with antituberculous drugs and with excision of large masses when the intracranial tension was high. Computed tomography (CT) has modified this approach. CT has resulted in earlier diagnosis and has been of help in monitoring the results of medical treatment of tuberculomas in children. With such monitoring there has been less need for surgical excision. At the same time, it has been realised that some caution is required towards our dependence on CT, as the image morphology of a tuberculoma could simulate other lesions like a glioma, and surgical excision needs to be carried out when in doubt or when there is no appreciable improvement in CT appearances with medical treatment.

[Role of computed tomography in extrapulmonary tuberculosis]

A retrospective evaluation of 65 computed tomographic investigations on 27 patients with proven disseminated extrapulmonary tuberculosis showed no CT changes characteristic for tuberculosis, except for a higher density of tubercular abscesses. In the majority of cases the extent of tubercular manifestations could only be exactly established after the CT investigation. With the aid of this information together with the clinical course of the disease, the timing, type and extent of operative measures could be determined. Finally, in comparison with conventional X-ray and sonography, computed tomography has proved to be superior for control of therapeutic procedures.

Intracranial tuberculomas in a child: regression on the CT scan under conservative therapy

The case of a four-year-old boy is reported in whom the diagnosis of multiple cerebral and cerebellar focal tuberculous infections ("tuberculomas") was made. The diagnosis was based on a positive skin test, a history of contact, typical x-ray findings in the lung, CSF findings, and CT scan. The patient was treated during a three-year-period with antituberculous therapy. Sequential CT scans showed a relatively slow modification of the lesions, during a period of at least eighteen months, and thereafter their almost complete regression.

[Cerebromeningeal tuberculosis. X-ray computed tomographic aspects apropos of 36 cases]

Thirty-six patients with different clinical and topographic forms of cerebromeningeal tuberculosis: meningitis, meningo-encephalitis, tuberculoma, abscess and their complications, were investigated by CT scans. Whereas standard films allow diagnosis of intracranial hypertension, other neurological examinations are very insufficient when compared with CT imaging, a non-invasive procedure which provides presumptive signs of a tuberculous lesion and thus assists diagnosis, and assessment and follow up of results of treatment. Meningitis and meningo-encephalitis are seen as isodense images of cisternae of base of skull with marked increase after contrast, which may provoke the appearance of hyperdense nodules. More or less widespread hypodensities are provoked by meningoencephalitis, cerebral tuberculosis appearing as an iso- or hyperdense mass forming an annular shape after contrast. Calcification is a rare finding and appears as punctiform zones in the center of a tuberculoma, while a tuberculous abscess has the identical appearance to that of a nodular tuberculoma.

Effect of medical treatment on intracranial tuberculoma--a CT study

Computerized tomography (CT) provides a non-invasive method for making a reasonably confident diagnosis of intracranial tuberculosis and an opportunity to study the response to treatment. Using this facility a series of 50 patients with intracranial tuberculomas, whose vision or life was not threatened by severe intracranial hypertension, were treated with antituberculosis chemotherapy. Most of the small and medium sized lesions resolved completely. Central liquefaction was observed in one case while only three failed to respond to treatment, there was one death. Three illustrative cases have been reported in detail.

The evaluation of contrast-enhancing brain lesions: pitfalls in current practice

The definitive diagnosis of space-occupying brain lesions can be established more readily since the advent of computerized tomographic (CT) scanning. Some brain lesions are more clearly defined when contrast-enhancing agents are utilized; however, so-called ring-enhancing lesions are not pathognomonic for specific neurological entities. Review of the literature suggests that at least four disorders must be considered in the differential diagnosis of contrast-enhancing lesions. These include mature brain abscesses of any etiology, cerebrovascular accidents, and primary or metastatic brain tumors. Since the medical and surgical management of these conditions is quite different, it is critical to establish a diagnosis before therapy is instituted. In many instances the combination of history, physical examination, laboratory, and radiologic examination will enable physicians to correctly diagnose the etiology of such brain lesions. However, we present two cases for which the above clinical and non-invasive parameters led to incorrect working diagnoses. Brain biopsy was required before appropriate management was eventually instituted. Potentially, such delays in diagnosis and institution of therapy can result in unnecessary morbidity and mortality. Each case illustrates the need to substantiate a presumptive diagnosis based on these clinical and radiographic criteria, regardless of how "typical" lesions may appear on CT scans.

Cerebellar tuberculoma: a rare disease in an industrialized country

A nine-year-old Somalian boy was treated in Denmark for a posterior fossa tumor, which proved to be a tuberculoma. This disease is virtually unknown in our highly industrialized country, which emphasizes the fact that due to increased international traveling, knowledge of endemic diseases in other parts of the world is necessary. The treatment of tuberculoma and their diagnostic features are reviewed.

Appearance of tuberculoma during the course of TB meningitis

A patient with tuberculous meningitis is described, who developed brainstem tuberculoma after 7 months of adequate drug therapy and while improving satisfactorily. The possible factors resulting in the development of tuberculoma are discussed. The tuberculoma responded to the medical therapy. Tuberculoma should be looked for if the condition of the patient worsens or if the patient develops new neurological signs during the course of TB meningitis.

Sequential computed tomography in tuberculous meningitis in infants and children

Clinical and serial CT findings in 9 children, mainly infants with advanced tuberculous meningitis are presented. Hydrocephalus, tuberculomas and brain infarction were common findings in the acute stage of the disease. CT scan, allowing the detection and follow-up of cerebral manifestations of tuberculosis, proved to be an accurate and effective diagnostic method, which should be used in all cases of tuberculous meningitis.

Granulomatous diseases of the CNS as demonstrated by computerized tomography

The CT findings in 32 patients with pathological conditions characterized by granulomatous disorders are reviewed. The characteristic CT finding in caseating granuloma due to tuberculous disease is a nodular enhancing lesion with a central hypodense region. The granulomas representing sarcoidosis show homogeneous enhancing nodular lesions. The granulomas due to cryptococcal fungal disease showed ring pattern with large central hypodense region which represented cyst formation. In certain vasculitides which affected the CNS and had pathological evidence of granuloma formation, CT showed nodular enhancing lesions. Based upon the CT findings, it was not possible to differentiate these nodular enhancing lesions which represented granulomatous disease from other intracranial diseases, i.e. abscesses, neoplasms, multiple sclerosis, gliosis.

Paradoxical expansion of intracranial tuberculomas during chemotherapy

4 patients with tuberculosis, 3 of whom had tuberculous meningitis, were noted to have tuberculomas on computed tomographic scanning. During antituberculous chemotherapy the intracranial lesions increased in size in all 4 patients at a time when the clinical state and cerebrospinal-fluid abnormalities were improving; in 2 of the patients the regional lymph nodes also enlarged greatly. Though the expansion of the cerebral lesions caused anxiety and led to some changes in chemotherapy, the lesions eventually diminished in size.

[Computed tomographic and roentgenologic evaluation of solitary pulmonary nodules]

One hundred patients with solitary intrapulmonary round lesions were examined by CT and conventional tomography in order to compare their value in reaching a diagnosis. Correct diagnosis as to whether the lesion was malignant was possible in 79% by tomography and in 84% by CT; the type of lesion was diagnosed correctly in 50% and 64% respectively. CT was superior to conventional radiography, particularly for the recognition of calcified tuberculomas. A density value was determined which, when exceeded, always indicated that the lesion was benign.

[Comparative evaluation of zono- and tomography in the differential diagnosis of small spherical formations in the lungs]

A comparative analysis of zono - and tomography in 69 patients with minor peripheral cancer of the lung (26), tuberculoma (24), hamartoma (19) was performed. Zonography was shown to improve differential diagnosis between them. However, its importance is limited and helps to better visualize changes of the lung tissue around the formations, "a path" outgoing to the pulmonary radix and chest wall, and to detect the enlarged intrathoracic lymph nodes. Tomography is of greater informative value for the evaluation of the skialogical features of the formations and pleural changes. The combined use of zono - and tomography results in a better detection of different pathological lung formations of small sizes and changes in the pulmonary tissue enhancing the efficacy of differential radiodiagnosis between them.

[Intracerebral tuberculoma. Clinical and x-ray computed tomographic characteristics]

Intracranial tuberculomas have become uncommon in industrial nations, while they still have a high incidence in underdeveloped countries. Four cases of intracerebral supratentorial tuberculomas are reported in this paper. Clinical findings suggestive of tuberculosis were present in only one case. The other cases were thought to be gliomas or metastases and the diagnosis was made only after surgery. The CT scan provided a good image of the lesions whose characteristics, however, were diagnostically confusing. When a tuberculoma is suspected, medical therapy alone should be administered initially. Surgery should be resorted to in cases of markedly increased intracranial pressure.

[Computer tomography aspects of benign intrathoracic space-occupying lesions]

We examined 55 patients with different, rare, benign intrathoracic lesions. Special computer-tomographic characteristics of the different tumours are demonstrated to help to differentiate from other malignant and benign tumours. In 37 of 55 tumours (67%) typical signs for the benign lesions could be shown. In 25 patients (46%) the preoperative diagnosis proved to be correct. While cystic, calcified and fat containing processes were assessed correctly by computed tomography, solid non calcified mediastinal and intrapulmonary tumours could not be classified as well.

Intracranial infection due to mycobacterium bovis in Hodgkin's disease

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Intradural extramedullary tuberculoma of the cervical spine. Case report

A case is reported of a 45-year-old man who developed quadriplegia following a trivial motor-vehicle accident. Investigation including computerized tomography (CT) of the cervical spine revealed a large calcified lesion displacing the spinal cord and nerve roots, which proved to be a tuberculoma. The case is unusual in regard to the age of the patient, the size, location, and nature of the lesion, the mode of presentation, and the delineation of the lesion by CT scanning.

Pulmonary air meniscus sign

In chest roentgenograms, the pulmonary meniscus sign is a crescent-shaped inclusion of air surrounded by consolidated lung tissue. The common cause is aspergilloma. A hydatid cyst is, however, the most common cause in endemic areas. In this study, 10 cases with meniscus sign are presented and the pertinent literature is reviewed.

Intracranial tuberculomas in a child: computed tomographic scan diagnosis and nonsurgical management

Despite great strides in screening and detection of tuberculosis, urban areas still harbor many children with this disease. The case of a child with probable intracranial tuberculomas who was medically treated with antituberculous therapy and followed with frequent computed tomographic (CT) scans is reported. Despite older textbooks that espouse surgery as the treatment for intracranial tuberculomas, it is suggested that in the era of CT scanning, they should be treated the same as other focal CNS infections. Surgery should be reserved for medical failure or deteriorating conditions.

Intracranial tuberculoma: conservative management

Twenty cases of intracranial tuberculoma were treated by us. A clinical-radiographic syndrome was recognized, consisting of an avascular enhancing mass lesion surrounded by marked edema and associated with relatively less severe clinical manifestations than would have been expected from the size and location of the lesion. This allowed successful medical therapy with three antituberculous drugs for an average of 12 months. Steroids, when used, were beneficial in relieving symptoms of cerebral edema without causing spread of tuberculosis. Medically treated patients had a significantly better functional recovery than those from whom the tuberculoma was excised.

Giant calcified and ossified midbrain tuberculoma. Case report

✓ A case of a giant calcified midbrain tuberculoma is presented. Although clinically the diagnosis of tuberculoma was suspected, the conclusive diagnosis could not be established before autopsy. Autopsy findings revealed an ossified and healed tuberculoma. The clinical and pathological findings are discussed.